APPLICATION TO
RENEW A
WELL DRILLER LICENSE
I. FILING FEE: A nonrefundable fee of $50 is required to accompany the application (Submit form in DUPLICATE)
II. GENERAL:
Name of Licensed Well Driller:
DBA or Company Name:
_______
Well Driller License Number:
Expiration Date:
Mailing Address:
City:
State:
Phone Number:
Email:
Drivers License #:
Zip Code:
State of Issue:
_______
Applicant is applying to renew a license for the following type(s) of drilling methodologies (check all that apply):
Cable tool drilling
Mud rotary drilling
Jetting and driving wells
Air rotary drilling
Reverse circulation drilling
III. DRILL RIG SUPERVISORS: List the drill rig supervisors that you employ in the table below (if new to your license,
you must attach a completed Drill Rig Supervisor Registration Form). You are responsible for the actions of each drill rig
supervisor that is supervising well drilling activities under your direction.
Name of
Drill Rig Supervisor
Years Employed by
You as a
Drill Rig Supervisor
Years of
Experience
CEU’s completed
during license/
registration period
IV. LIST OF DRILL RIGS: List your active drill rigs in the table below. If a Drill Rig Form has not been filed for any of
your active drill rigs, attach a completed Drill Rig Form to this application.
Name of Rig (or ID Number)
Number of Years
in Service
Is a Well Rig Form on File at the Office
of the State Engineer?
Application to Renew a Well Driller License
Version: December 1, 2014
Page 1 of 3
V. CONTINUING EDUCATION: Please attach copies of form WD-05, Documentation of Continuing Education Hours;
complete one form for the licensee and one for each drill rig supervisor employed by the licensee. Form WD-05 shall be
accompanied by all applicable Certificates of Course Completion and any other documentation necessary to demonstrate that
you and your drill rig supervisors have earned the required continuing education credit hours.
VI. ATTACHMENTS:
Is proof of general liability insurance in the amount of $300,000 (or greater) attached?
Is proof of bond in the penal sum of $5000 (or greater) attached or is your bond continuous?
Is proof of workmen’s compensation insurance attached?
VII. AFFIDAVIT:
I,
, being first duly sworn, upon my oath, depose and say that I have
carefully read the foregoing applications, statement and attachments, which are a part hereof; that I am familiar with the rules
and regulations of the State Engineer pertaining to the drilling of wells and will comply with them, and that each and all of
the statements in the application, statement and attachments are true to the best of my knowledge and belief.
Signature of Applicant
State of New Mexico
County of
This instrument was acknowledged before me this
day of
, 20
My Commission Expires
Signature of Notarial Officer
VIII. ENDORSEMENT OF CORPORATE SURETY:
I,
, Attorney-in-Fact for
,
of
, State of
, as surety of the Well Driller’s Bond
executed
, wherein
is the
principal, and identified as our Bond No.
on file with the State Engineer, Santa Fe, New Mexico, being
first duly sworn, upon my oath, depose and say that said bond is now in force and effect and that said bond will remain in
force and effect until such time as it may be cancelled in compliance with the rules and regulations of the State Engineer of
New Mexico.
Signature of Attorney-in -Fact
State of New Mexico
County of
This instrument was acknowledged before me this
day of
, 20
My Commission Expires
Signature of Notarial Officer
Application to Renew a Well Driller License
Version: December 1, 2014
Page 2 of 3
IX. ENDORSEMENT OF THE STATE ENGINEER:
License No.
Expiration Date:
Licensed Drilling Methods:
This application for renewal is approved and license is hereby reissued to the applicant to drill water wells of the types
described above provided that the applicant complies with all rules and regulations of the State Engineer pertaining to wells.
Witness my hand and official seal this
day of
,
Tom Blaine P.E., State Engineer
By:
Application to Renew a Well Driller License
Version: December 1, 2014
Page 3 of 3